Person-Centered Multimorbidity Care in UK Primary Care: Identifying Changes to Practice

Growing numbers of people live with multimorbidity, defined as 2 or more long-term health conditions. Health care delivery must adapt to manage the growing workload and complexity associated with multimorbidity. Research, practice, and policy have called for a shift to whole-person tailored primary care management of multimorbidity but have yet to adequately describe how this should be implemented. Here, we systematically identify the enablers and barriers to delivery of tailored care for people living with multimorbidity to develop a new model for implementation.

We collected data across 5 UK general practitioner (GP) sites through 2 methods: ethnography and focus group discussions. Ethnographers observed 25 consultation sessions, 5 per site. Focus groups were held among primary care staff (n = 16, across 4 sessions) and patients and carers (n = 8, across 2 sessions). We analyzed integrated data using inductive thematic analysis to describe enablers/barriers to delivery of tailored care.

We identified 3 elements needed to enable tailored management: (1) resources for tailored assessment of, and practical support for, tailored management of multimorbidities, (2) engagement of patients/carers with professional collaboration to cocreate tailored management plans, and (3) evaluation and development of the professional skills required to confidently work beyond traditional condition-focused models.

Whole-person tailored care needs inclusion of more services in routine primary care and change of culture toward shared decision making among multidisciplinary health care teams, patients, and carers. Such approach needs flexible consultation models and data sources enforced through monitoring and continual learning.